Prevention of Future Deaths reports · 2025

Sheila Nicholls

Regulation 28 report to prevent future deaths, reference 2025-0009, written 7 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report7 Jan 2025
Reference2025-0009
DeceasedSheila Nicholls
CoronerMichael Walsh
Coroner areaBuckinghamshire
CategoryCare Home Health related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

THE BEACONSFIELD CORONER’S COURT 

IN THE MATTER OF AN INQUEST TOUCHING THE DEATH OF 

SHEILA ANN NICHOLLS 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1.  Mandeville Grange Nursing Home 

1 

CORONER 

I am Michael Walsh, HM Assistant Coroner, for the coroner area of Buckinghamshire 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

https://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 

https://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

The inquest into the death of Ms Sheila Ann Nicholls, aged 80, was opened on 22nd 
November 2023. The investigation concluded at the end of the inquest on 23rd October 
2024. 

The medical cause of death was: 
Ia   Hypoxia 
Ib   Food Bolus Obstruction of Upper Airway 

II   Severe Ischaemic Heart Disease (Stented) 

The Narrative conclusion to the inquest was: 
Sheila choked on food during a short period of respite care, at Mandeville Grange 
Nursing Home on 19.11.2023. Information on Sheila’s swallowing problem was provided 
to the nursing home staff by family members, but the nursing home’s assessments and 
checklists and handovers either omitted or did not share that information or the risk it 
presented, with all relevant staff. Breakfast was therefore given to Sheila that did not 
take her swallowing problem into account. Sheila subsequently choked on toast, 
suffering hypoxia that led to a cardiac arrest and what was an otherwise avoidable 
death. Neglect contributed to the cause of death. 

4 

CIRCUMSTANCES OF THE DEATH 

Sheila died due to choking on food only a day after entering the nursing home on 
18.11.2023 as a respite care resident.  Her family warned the nursing home of Sheila’s 
swallowing difficulties and a need for monitoring whilst eating and to avoid certain foods, 
but important information went unrecorded and was not shared between staff, resulting 
in Sheila being provided with food she should not have been given and/or should have 
been prepared differently. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 On 19.11.2023 Sheila was given breakfast on which she choked, requiring emergency 
assistance from staff, only one of whom had valid current life support training, and the 
emergency response included ineffective CPR.  Sheila died from choking on the food 
provided. 
CORONER’S CONCERNS 

5 

During the course of the inquest the evidence revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths could occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

Concerns directed to Mandeville Grange Nursing Home 

CONCERNS 

Management and circulation of internal written policies: 

1.  Mandeville Grange Nursing Home considered several existing policies required 
improvement, and so they were rewritten following Sheila’s death, some using 
template documents from a health and safety outsourcing website.  However, some 
rewritten policies still included clauses that remained irrelevant to the nursing home 
(e.g. regarding ‘oral suction devices’), and several policies remained undated and 
unsigned, and it was therefore far from clear which policies had been ratified and 
were in force; with poor version control overall. 
It was not always clear when policies had been written or by whom; when and by 
whom they had been reviewed; and if and when they were circulated, and to which 
staff members. 
It was also unclear from the evidence of staff members, whether policies were 
properly embedded and/or understood, and/or had been read by all staff, as there 
were no checklists confirming staff had read and understood the policies. 
At the time of the inquest, staff training on new policies was said to be ongoing, and 
planned staff competency assessments had yet to be arranged. 
Deficient management of internal policies creates a risk of death to future residents 
where there is an inability to verify and record that all policies: 
(a)  are relevant to Mandeville Grange in the first instance; 
(b)  have been ratified and are in force; 
(c)  have been reviewed as required; and 
(d)  have been circulated to all relevant staff, with confirmation of those policies 

having been read and understood. 

Training in emergency response: 

2.  At the time of Sheila’s death, of the several staff members that responded to her 

choking emergency, only one staff member (nurse GC) had currently valid training 
in life support, but still undertook CPR ineffectively without being corrected by other 
staff.  
Evidence was also given that no simulated emergency drills were ever performed, 
and some staff were never aware their training had expired. 
Whilst nurse GC still works for Grange Mandeville Nursing Home, it is unclear how 
that nurse will be supported in their ability to provide an adequate emergency 
response, bearing in mind their existing training appears to have been insufficient. 
The deficiency in training and embedding that training, both generally for all staff, 
and for that specific nurse, creates a risk of death to residents should future 
emergencies arise. 

Investigating and learning from adverse incidents: 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  Evidence was given of two internal investigations undertaken by Mandeville Grange 
management following Sheila’s death, both of which failed to adequately consider 
significant matters.  The investigations were performed by staff untrained in 
investigating adverse incidents.  The inability to adequately investigate such matters 
creates a risk of death to future residents given deficiencies in care may not be 
identified or remedied in a timely manner. 
At the time of the inquest, the nursing home’s expressed intention was to instruct an 
external person or organisation to investigate future unexpected or unnatural 
deaths. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe your  
organisation has the power to take such action in relation to the concerns above. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 5th March 2025. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise, you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons: 

1.  Sheila’s son 
2.  Sheila’s daughter 
3.  Mandeville Grange Nursing Home 
4. 
5. 

, former clinical lead nurse at Mandeville Grange Nursing Home 
, RGN, at Mandeville Grange Nursing Home 

I have also sent it to: 

the Care Quality Commission, 

who may find it useful or of interest. 

I am also under a duty to send the Chief Coroner a copy of your response.  

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

7th January 2025 

Michael Walsh 
HM Assistant Coroner 
Beaconsfield Coroner’s Court 

3

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Mandeville Grange Nursing Home (PDF)
FAO Mr Michael Walsh
HM Assistant Coroner
c/o Ms Margaret Mullin, Coroner’s Officer

By Email: 

Dear Sir

5 March 2025

Inquest touching the death of Ms Sheila Ann Nicholls
Response to Regulation 28 Report to Prevent Future Deaths

On 8 January 2025 following the conclusion of the Inquest touching the death of Ms Sheila Ann Nicholls a
Prevention of Future Deaths (“PFD”) report was issued.

We respond to that report by way of this letter.

To confirm, the report was shared with 
email and postal address was provided to Ms Mullin on 9 and 10 January 2025.

 on 9 January 2025 via email. 

’s

(1) Management and circulation of internal written policies

At  the  time  of  the  Inquest  in  October  2024,  we  had  instructed  Care4Quality  (“C4Q”)  to  assist  around  our
admissions  process.  We  were  considering  whether  or  not  it  was  practical  for  them  to  manage  our  suite  of
policies in totality.

Having considered this further, we took the decision to engage C4Q to re-write all of our policies to ensure they
  (our new
are  (i)  relevant  (ii)  specific  and  (iii)  that  we  remain  up  to  date with  current  legislation. 
Nominated Individual) is managing this process.

Beginning in October 2024, C4Q now work closely with our Home Managers to review and thereafter tailor the
policies to the specific requirements of our services. The process is:

1.
2.

Drafting: C4Q prepare a near-final draft of the policy and send it to the Home Manager for review.
Review: The Home Manager reviews the draft and provides any feedback or queries to C4Q.

 3.

4.
5.

Finalisation: Once all discussions have taken place, and revisions agreed upon, the policy is deemed
finalised.
Upload: The policy is then uploaded to C4Q’s policy platform, Astute, which our team has access to.
Distribution: Our HR team then uploads the final policy to Bright HR, our HR platform. This enables
direct  circulation  to  staff.  The  date  the  policy  is  uploaded  to  Bright  HR  is  the  date  the  policy  is
deemed in force.

In terms of onward monitoring and review:

6.
7.

8.

9.

10.

Review: policies are reviewed yearly, or in the event of new legislation or guidelines / guidance.
Acknowledgment:  Bright  HR  generates  both  a  “read  receipt”  to  confirm  that  all  staff  members
have read the policy and an “acceptance receipt” to confirm that all staff members have both read and
accepted the contents.
Communication: Any new or updated policies are discussed during the daily flash meetings, which
are recorded in meeting minutes.
Monitoring:  Each  week,  the  HR  team  meets  with  the  Home  Manager  to  review  staff  compliance
data on Bright HR and follow up on any outstanding acknowledgments.
Training:  If  additional  training  is  required  as  a  result  of  a  new  or  updated  policy,  the  need  is
identified in the weekly Manager/HR meeting, and the necessary training is then scheduled.

In terms of the project’s current status:

- We have 85 policies in circulation;

-
-

-

nalised;

54 are fi
17 are with the Manager for final review; and
14 are still in a drafting phase.

It is envisaged all 85 policies will be in force by 30/04/2025.

For the avoidance of doubt in place already are:

-
-
-
-

Initial Assessment and Admissions Policy;
Person-Centred Care Policy;
Nutrition and Hydration (including dysphagia); and
Resuscitation Policy (including choking).

(2) Training in emergency response

Effective from 14 October 2024, we transitioned the majority of our training to an eLearning format provided by
The  Access  Group  (Access  Learning  for  Care).  This  platform  automatically  generates  a  training  matrix  for
Mandeville Grange and also records any face-to-face sessions, ensuring the matrix remains accurate and up to
date.

Our HR team and the Home Manager meet weekly to review the matrix, and any face-to-face training that is
due to expire within two months is immediately scheduled with one of our external trainers.

 To maintain consistency in our face-to-face training, we have recently engaged four additional trainers.

For  eLearning  modules,  the  Access  system  sends  automatic  reminders  to  staff  members  three  weeks, two
weeks, and one week before their training expires.

Our current training matrix indicates 100% compliance. There is some training which is scheduled to expire
within one month. That training will be organised in good time.

We have not carried out any emergency CPR drills to date as we have been trying to work through a process
document to ensure that what we put in place is fit for purpose. The document is now finalised however the
starting  of  drills  is  awaiting  assessment  of  staff  competency  who  will  deliver  the  training.  This  will  happen
within 1 month.

We  have  ordered  a  PractiMan  Advanced  CPR  Adult/Child  Manikin,  2-in1  Life-like  CPR  Training  Manikin  for
Adult/Child CPR Training for the home.

By way of additional information: 
 left her role with Mandeville on 25 October 2024.
Steps had begun to be taken to provide her with additional training and supervision, but unfortunately could not
be completed before she left.

(3) Investigating and learning from adverse inferences

We remain committed to instructing an external person or organisation to investigate any future deaths.

There has been one incident and Fulcrum Care completed a Root Cause Analysis for this.

We hope the above demonstrates how seriously the concerns raised have been taken.

Yours sincerely

Chief Executive Officer
Chiltern Care Services

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